Title of Case(s)

DISSEMINATED DISEASE IN AN IMMUNOCOMPROMISED CHILD

Background

Invasive mould infections are a significant cause of morbidity and mortality in immunocompromised children.

The emergence of azole-resistant disease, with associated poor clinical outcome, is an ever-increasing challenge, requiring expert MDT input.

Case Presentation Summary

An 11 year old girl, with a background of recently diagnosed ALL, presented with acute onset of headache and decreased level of consciousness. Urgent neuroimaging revealed right cerebellar abscess (4x3x2cm) with supratentorial extension, moderate mass effect and early obstructive hydrocephalaus. Emergency neurosurgery involved partial resection of abscess and broad spectrum antibiotic and antifungal agents were commenced. Further imaging revealed pulmonary and hepatic lesions consistent with invasive fungal disease(IFD).

Cerebellar biopsy grew Aspergillus fumigatas which was pan-azole resistant (MIC ~4) but highly sensitive to amphotericin (MIC 0.5) International experts recommended dual-agent approach with amphotericin (l-amb) 3mg/kg OD and isavuconazole (Isavu) 10mg/kg OD. Serum & CSF TDM was strictly monitored, with aim for supratherapeutic Isavu levels of 4-6mg/L.

She is now almost 18 months into IFD treatment.No further surgical interventions have occurred. Serial imaging has revealed >50% size reduction of the cerebellar abscess remnant, improvement in pulmonary nodules and normalisation of liver appearances. Her treatment course has been complicated due to repeated acute kidney injuries requiring multiple hospital readmissions, prompting initial dose adjustment and then discontinuation of l-amb. Recently, new persistent neutropenia (ANC 0.3-0.9) has warranted investigations to exclude primary disease relapse. Despite the significant improvement and progress, her journey remains challenging and prognosis guarded.

Key Learning Points

Current recommendations suggest IV Voriconazole is the most effective evidenced-based treatment for invasive aspergillosis.
Novel agent isavuconazole, whilst unlicensed and has limited long-term safety data, appears to be as effective with a more favourable side-effect profile and more predictable PK/PD behaviour.

In cases of pan-azole resistant CNS aspergillosis, a multidisciplinary team including ID experts, mycologists, microbiologists , pharmacists and neurosurgeons should be involved.